ArticleLiterature Review

Diverticulosis of the appendix: A collective review

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Abstract

The classification, incidence, and pathogenesis of diverticula of the appendix are discussed. Review of the literature reveals 1,373 instances of appendiceal diverticula. Forty-three were “true” or congenital diverticula, and 1,330 were “false” or acquired diverticula. Twenty-four additional cases from the University of Michigan Medical Center are described.

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... About 50 cases have been reported until today. 1 It classically has two variants: congenital and acquired. 2 Congenital diverticula are real diverticula including mucosa, submucosa, serosa, and, most importantly, the muscular layers. Acquired diverticula are false structures which do not have a muscular layer. ...
... 4 Diverticula are seen in 2.2% to 0.3% of the population, the majority of which is acquired. 2,5 Congenital diverticula are very rare with a 0.014% of incidence. 3,6 Acquired diverticula are often multiple and are seen in the mesoappendix. ...
... 7 Congenital diverticula are generally single and are seen at the antimesenteric side of the appendix. 2,6 On the contrary to the literature, in our case, the diverticula were both multiple and located unexpectedly at the mesenteric side of the appendix. Furthermore, on the walls of all fistulas tracts, there were layers of serosa and muscle, in addition to colonic epithelium according to the microscopic examination. ...
... About 50 cases have been reported until today. 1 It classically has two variants: congenital and acquired. 2 Congenital diverticula are real diverticula including mucosa, submucosa, serosa, and, most importantly, the muscular layers. Acquired diverticula are false structures which do not have a muscular layer. ...
... 4 Diverticula are seen in 2.2% to 0.3% of the population, the majority of which is acquired. 2,5 Congenital diverticula are very rare with a 0.014% of incidence. 3,6 Acquired diverticula are often multiple and are seen in the mesoappendix. ...
... 7 Congenital diverticula are generally single and are seen at the antimesenteric side of the appendix. 2,6 On the contrary to the literature, in our case, the diverticula were both multiple and located unexpectedly at the mesenteric side of the appendix. Furthermore, on the walls of all fistulas tracts, there were layers of serosa and muscle, in addition to colonic epithelium according to the microscopic examination. ...
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Introduction Congenital anomalies of the appendix are extremely rare. They are usually found incidentally during operations other than appendectomies. Congenital appendix diverticula are even less frequent. Discussion Congenital caeco-appendiceal fistulae have not been reported until today. Herein, we present real diverticula of the appendix with multiple caeco-appendiceal fistulae which, to our knowledge, is the first in the literature.
... Appendiceal diverticula are classically divided into acquired and congenital types. [2][3][4][5][6][7][8][9][10] The majority are acquired with an incidence range between 0.004% and 2.1% from appendicectomy studies, and an incidence range between 0.20% and 0.66% from autopsy studies. [6][7][8][9][11][12][13][14][15][16] Collins 3 studied 50 000 autopsy and appendicectomy specimens and came with a collective incidence of 1.4%. ...
... Appendiceal diverticulitis is a discrete clinicopathological inflammatory disease that is different and distinct from the usual acute appendicitis. 6,7,10,12 Acquired appendiceal diverticulosis and diverticulitis usually Diverticulosis of the appendix is a relatively rare pathological finding. The majority are acquired pseudodiverticula. ...
... Acquired diverticula are most commonly found in the distal one third of the appendix (60%). 3,7,8,10,17 When multiple they impose a beaded appearance of the appendix. 31 They are usually found along the mesenteric border of the mesoappendix but can be seen along the antimesenteric border, as well 5 ( Figure 1). ...
Article
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Diverticulosis of the appendix is a relatively rare pathological finding. The majority are acquired pseudodiverticula. True congenital diverticula are very rare. Appendiceal diverticulosis is usually an incidental finding and clinically asymptomatic. When symptomatic, it is usually complicated by acute or chronic diverticulitis with or without acute appendicitis. It presents with atypical abdominal signs and symptoms, mostly in adult males. Appendiceal diverticulitis is a distinct entity with several clinical and pathological differences from acute appendicitis. It has a more rapid progression to perforation and a higher rate of mortality. Therefore, appendiceal diverticulitis should be considered in the clinical differential diagnosis, especially in adult males with chronic abdominal pain. Appendiceal diverticulosis demonstrates a significant association with obstructing or incidental appendiceal neoplasms. It may play an important role in the development of pseudomyxoma peritonei, which is associated with appendiceal mucinous tumors. Therefore, meticulous gross examination and thorough histological examination of the entire appendicectomy specimen are essential. When discovered either by preoperative radiological investigations or during an exploratory operation, prophylactic appendicectomy is advocated to prevent the risk of complications and to rule out the possibility of a coexisting neoplasm.
... Diverticula of the appendix (DA) are infrequent, either congenital or acquired, and reportedly present in 0.004% to approximately 2% of sectioned specimens [1][2][3]. They are defined as a herniation of mucosa and muscularis mucosa through a vascular hiatus in the wall of the appendix. ...
... The arrow indicates diverticulum of 17.5% in our study is comparable to that in the current Australian experience [10,11]. The rate of DA in the present retrospective study (2.1%) was within the range quoted in earlier reports [1][2][3]. While other authors have noted that older patients were more likely to develop appendiceal diverticulitis [9], there was no significant difference in age in this cohort of DA patients with or without diverticulitis. ...
Article
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Introduction: Diverticula of the appendix (DA) have a reported incidence of up to 2.1%. They are primarily detected incidentally, through imaging and intraoperative or histologic diagnosis. This study's objective was to examine the prevalence of DA, and its relationship with inflammation and neoplasia, as well as review the literature with respect to clinical outcomes and ability to identify DA preoperatively. Methodology: A retrospective search of all patients undergoing an appendicectomy for right lower quadrant pain at a single institution between 2004 and 2017 was conducted. Histopathology reports for evidence of DA, location of the DA, presence of inflammation, and any relationship between DA and neoplasms (adenoma, carcinoma, carcinoid, lymphoma, and mucinous neoplasm) within the appendix were reviewed. Clinical notes, operative records, and preoperative imaging were also reviewed. Results: Two thousand seven hundred eleven patient were included in the study, with a mean age of 34 years, with acute appendicitis found in 82.5%. 31.6% of patients with DA had associated inflammation of the DA. DA was present in 57 patients (2.1%), with 55 patients in the total cohort having neoplasia (2.0%). Patients with DAs were ten times more likely to have appendicular neoplasm than patients without a DA (17.5 vs 1.8%; p < 0.0001, OR 11.8 95%, CI 5.6-24.8). Conclusion: This is the first Australian study demonstrating DAs are a significant marker of appendiceal neoplasm. Appendicectomy in all incidentally discovered diverticulum should be considered. Due to a paucity of data, research is required into this area to assess for the need for endoscopy following diagnosis.
... While colonic diverticular is common, acquired appendiceal diverticulosis (AD) is rare, found in 0.004-2.1% of all appendectomies, and 0.2-0.66% of autopsy specimens (2,3). Their co-existence is extremely uncommon, with fewer than 10 case reports and case series worldwide ( Table 1) (4)(5)(6)(7)(8)(9)(10). Some authors have postulated a correlation between the formation of AD and space-occupying appendiceal lesions that raise intra-luminal pressure (2,8,11,12). ...
... , and two were described 50 to 100 years ago ( Table 1) (9,10). PAA is also rare, accounting for 0.5% of all gastrointestinal malignancies, with an age- adjusted incidence of 0.12 cases per 1,000,000 people per year (17)(18)(19). ...
Article
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Diagnosis of primary appendiceal adenocarcinoma (PAA) is hindered by its rarity and largely asymptomatic nature. Appendiceal diverticulosis (AD) is equally rare. We report an unusual case of PAA presenting with perforated appendiceal diverticulitis, and discuss a review of the literature about its association, and its surgical and pathological implications. A middle-aged man was admitted with right iliac fossa (RIF) pain and a corresponding tender abdominal mass for 5 days. Computerised tomography (CT) scan demonstrated a thickened appendix with 3 cm abscess at its base. During laparoscopic appendicectomy, the appendiceal phlegmon was adhered to the surrounding bowel. Histology showed a perforated diverticulum near the appendiceal tip, and a primary appendiceal well-differentiated adenocarcinoma located proximal to it with clear margins. Up to 48% of ADs are associated with appendiceal neoplasms, but its coexistence with PAA is reported in fewer than ten instances worldwide. Obstructing appendiceal tumours, by raising intraluminal pressure, can predispose to AD formation. Intestinal-type PAA is often managed like its colorectal counterpart, although controversies about management of PAA in a perforated AD remain. Recognition of the association of AD and PAA is critical to ensure meticulous oncological resection and histological examination.
... Diverticula are small, bulging pouches within the bowel wall that typically form within the large intestine, including the appendix. Appendiceal diverticula are relatively rare [1] . Appendiceal diverticulitis is the result of inflammation of the appendiceal diverticulum. ...
... This is similar to the anatomical derangement seen in diverticula of the colon. Since the incidence of appendiceal diverticulitis among patients undergoing appendectomy has been reported to vary from 0.004% to 2.1% [1] , appendiceal diverticulitis has been considered very rare. However, in our study, appendiceal diverticulitis was found to be a relatively common condition. ...
Article
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To study the clinical features and computed tomography (CT) findings of appendiceal diverticulitis vs acute appendicitis. We retrospectively reviewed the records of 451 patients who had undergone appendectomy in our institution from January 2007 to September 2012. Patient demographics, clinical features, pathological findings, and surgical outcomes were analyzed. We also compared preoperative CT images of 25 patients with appendiceal diverticulitis with those of 25 patients with acute appendicitis. Among 451 patients, 44 (9.7%) were diagnosed to have appendiceal diverticulitis and 398 (86.9%) to have acute appendicitis. Patients with appendiceal diverticulitis were older (59 vs 37 years, P < 0.001) and had a longer duration of the illness (4.0 d vs 1.0 d, P < 0.001). Perforation rates in patients with appendiceal diverticulitis were higher (68% vs 27%, P < 0.001). The appendix could be visualized in only 13 patients (52%) among the appendiceal diverticulitis cases, but in all acute appendicitis cases. CT findings suggestive of appendiceal diverticulitis included the absence of fluid collection in the appendix (84% vs 12%, P < 0.001), absence of appendicolith (92% vs 52%, P = 0.005), and formation of abscess (68% vs 16%, P < 0.001). Appendiceal diverticula were identified in 6 patients (24%). Among patients who had undergone appendectomy, 9.7% had appendiceal diverticulitis. Patients with appendiceal diverticulitis had different clinical features and CT findings from patients with acute appendicitis.
... The disease is more common in men, is usually accompanied by previous attacks of pain, and presents fewer gastrointestinal symptoms [1,4] . Those with appendiceal diverticulitis are four times more likely to have a perforation compared with simple appendicitis, which is thought to be responsible for a longer convalescence and 30-fold more mortality [1,4,6,7] . Importantly, the incidence of perforation in cases of diverticulitis was 66% [6] . ...
... Those with appendiceal diverticulitis are four times more likely to have a perforation compared with simple appendicitis, which is thought to be responsible for a longer convalescence and 30-fold more mortality [1,4,6,7] . Importantly, the incidence of perforation in cases of diverticulitis was 66% [6] . However, the way of perforation, whether to free peritoneal cavity or into retroperitoneal space is not well documented. ...
Article
We report a case of a 32-year-old woman with episodic right lower quadrant abdominal pain. With the diagnosis of either acute appendicitis or tubo-ovarian abscess, she was treated with antibiotics, which successfully relieved the pain and the inflammatory findings. She repeated the clinical condition a few times and antibiotics worked each time. In a year, her subjective symptoms became milder, however, a giant pelvic cyst appeared. She had an exploratory laparotomy to confirm this diagnosis. Histopathological studies revealed herniated appendiceal mucosa through the muscular layer associated with chronic inflammation and marked fibrosis. Gynecological disorders such as endometriosis or lutein cyst rupture was denied. These findings represent appendiceal diverticulitis. We discuss the clinical features of the disease and its relation with the pelvic pseudocyst.
... Se ha propuesto que estos divertículos son originados por un aumento de presión en los puntos menos resistentes de la pared apendicular 10 y corresponden a menos del 1% de los casos. Los divertículos adquiridos pueden ser únicos o múltiples 11 , se localizan en el tercio distal del apéndice sobre el borde mesentérico y poseen un tamaño pequeño (2 mm-5 mm) 12 . Se han descrito algunos factores de riesgo para presentar divertículos apendiculares de forma adquirida: sexo masculino, edad mayor a 30 años, fibrosis quística y enfermedad de Hirschprung 1 . ...
Article
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La diverticulitis apendicular es una enfermedad poco frecuente con una incidencia aproximada de 1%. Se define por la presencia de divertículos verdaderos o falsos en la pared del apéndice cecal.Durante la fase aguda posee una clínica indistinguible a la apendicitis, sin embargo en ocasiones presenta características clínicas particulares que la distinguen de la apendicitis aguda tales como la presencia de dolor abdominal insidioso o intermitente y/o ausencia de sintomatología gastrointestinal (náuseas, vómitos o anorexia).En la diverticulitis apendicular las técnicas imagenológicas son de utilidad limitada al otorgar información inespecífica, por lo que el diagnóstico tiende a realizarse mediante el estudio anatomopatológico del apéndice posterior a una intervención quirúrgica en paciente con cuadro clínico compatible con apendicitis aguda.El tratamiento de elección corresponde a la apendicectomía, lo que permite evitar complicaciones futuras como por ejemplo perforación apendicular, neoplasias, entre otros.
... Acquired appendicular diverticula could originate from mucosa protrusion through a 'locus minoris resistentiae' at the level of a vascular hiatus. The pathophysiology of appendiceal diverticulitis is the same known for colonic diverticulitis: lumen obstruction induced by solid or fluid material determines inf lammation of the thin diverticular walls and associates with higher perforation rate (30-66%) [8][9][10]. ...
Article
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Appendicular diverticulosis is a rare condition observed in about 0.004–2% of all appendectomy specimens. Risk of perforation/bleeding is high and a relevant association with mucinous neoplasms is known. Appendectomy is indicated even in case of occasional finding. We present the case of a 22-year-old man who entered the Emergency Room for pain in right iliac fossa. Blood tests showed only a slight increase in C-reactive protein. Abdominal ultrasound (US) evidenced an appendix with thickened walls and a rounded fluid-filled hypoechoic lesion at its distal tip. Laparoscopic appendectomy confirmed the presence of mucocele. Postoperative course was uneventful and the patients discharged on postoperative day 3. Histological examination indicated diverticulitis/peridiverticulitis of the appendix and acute suppurative appendicitis. No perforation of the diverticula was detected. No neoplastic epithelium/mucous material was observed. In our case, preoperative US proved to be a useful alternative to computed tomography for the diagnosis.
... AD usually occurs in the 3rd decade, whilst acute appendicitis presents much earlier than that. Thus, AD should be considered as one of the differentials in adult male patient presenting with right lower quadrant pain or tenderness [5,7,8]. ...
... Diverticula of the appendix can be either acquired or congenital. Congenital diverticula are rarer and generally seen as a single diverticulum, but the acquired form is usually diverticulosis [6]. Congenital diverticula are generally true and consist of the mucosa, submucosa, serosa, and muscular layers, while the acquired diverticula are usually false and lack the muscular layers [7]. ...
Article
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Diverticulosis and sessile serrated adenomas of the colon are common findings on routine colonoscopy. However, diverticulosis of the appendix is rare and is usually only discovered due to conversion to diverticulitis or as an incidental finding. Diverticulitis of the appendix can present as appendicitis but is associated with more risks. A pathology report is important in diverticulosis of the appendix due to the association with malignancy. This case report reviews a 52-year-old female who presented to the emergency department with right lower quadrant pain who was diagnosed with acute appendicitis and was incidentally found to have diverticulosis of the appendix with a sessile serrated adenoma.
... Kialakulásának mechanizmusa pontosan nem ismert, de erre nézve is számos teória létezik, melyeket két csoportra oszthatunk. A gyulladásos elmélet szerint a megelőző gyulladásos epizódok a lumen szűkületét és a nyirokszövet atrófiáját okozzák, melyek következményeként az appendix fala elvékonyodik, meggyengül, ezzel lehetőséget teremtve a kiboltosulások kialakulására [8][9][10]. A másik elmélet szerint az áldiverticulumok keletkezését a másodlagosan -székletkő, gyulladásos szűkület, tumor következtében -kialakult idült intraluminaris nyomásnövekedésre vezethetjük vissza, amikor a nyálkahártya az izomréteg szerzett (gyulladás) vagy eredendően (artériák belépési pontjai) meglévő gyengébb pontjain türemkedik ki [5]. ...
Article
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Diverticulitis of the vermiform appendix is a rare disease with clinical features often similar to conventional acute appendicitis. The importance of appendiceal diverticulosis is the fact that it can lead to an early and a higher incidence of perforation and therefore a higher mortality rate, in contrast to acute appendicitis alone. In this study we present the clinicopathology, diagnosis and therapy of the disease with a review of the literature. A 65-year-old woman presented to the emergency department with a 48-hour history of intermittent pain in the right iliac fossa. Abdominal ultrasound raised the possibility of acute appendicitis but because of the relative asymptomatic state of the patient, the lack of fever and rebound tenderness we started observation. After 2 days with episodic abdominal pain, the patient was taken to the operating theatre for laparoscopic exploration. Intraoperatively, multiple diverticula were noted on the appendix and appendectomy was performed. Histopathological examination revealed diverticulosis and inflammation of the appendiceal wall. Due to the possible complications, the difficult preoperative diagnosis and its frequent association with appendiceal neoplasm, appendiceal diverticulosis requires special attention. For asymptomatic cases, incidentally diagnosed intraoperatively or discovered by radiology prophylactic appendectomy is recommended. Orv Hetil. 2018; 159(19): 768-772.
... Appendiceal diverticula can be congenital (true) or acquired (pseudodiverticula); the latter are the more common ones (97%), located mainly at the mesenteric edge of the distal third of the appendix [2]. There are various theories about its origin, e.g. the presence of weak spots in areas of the appendiceal wall with vascular structures, the pressure rise in appendiceal lumen due to (benignant or malignant) obstruction, or secondary to inflammatory reactions [3][4][5]. Its most common clinical presentation is the appendiceal diverticulitis which appears with symptoms similar to acute appendicitis, though it shows a subacute presentation and absence of gastrointestinal symptoms and evidence of systemic inflammatory response. ...
Article
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Background: The appendiceal diverticulum is an uncommon pathology. Its most common clinical presentation is the appendiceal diverticulitis and the symptoms are similar to acute appendicitis. Also, it can be considered as part of differential diagnosis for chronic abdominal pain. Aim: Analyze the prevalence in our hospital of appendiceal diverticulosis in acute appendicitis and literature review. Methods: Retrospective description study (January 2004 to December 2013) looking for presence of appendix diverticula in 1526 patients after appendectomy due to suspicion of acute appendicitis. Review of literature for term results: “appendiceal”, “appendicular”, “diverticulitis”, “diverticulosis”. Results: Total sample: 2058 patients operated of appendectomy; 1526 of those were to suspicion of acute appendicitis and in 38 of those we found presence of appendiceal diverticula (2.49% prevalence). Distribution: men/ women (68.42%/31.57%), middle age (46.71 years). Lipton classification: Type I (28.94%), type II (34.21%), type III (21.05%) and type IV (15.78%). Other associations: carcinoid tumor (2.36%), villous adenoma (2.63%), serrated adenoma with low grade dysplasia (2.63%), perforated diverticula (7.89%), chronic diverticulitis (5.26%). Conclusion: Prevalence is slightly higher in our series, probably because we considered only patients with acute appendicitis and not all surgical specimens with cecal appendix. According to reviewed bibliography there is possible relation with appendix neoplasias, more risk of perforation and mortality. It is a difficult pre-operative diagnosis and it has to be considered in the differential diagnosis for (acute and chronic) abdominal pain in right iliac fossa.
... Diverticulosis of the vermiform appendix can be congenital or acquried,with the congenital cases being very rare.It is probably associated with Group D chromosomal trisomy 13-15 (12,13) .Pathological analysis revealed presence of an acquired diverticulosis in our case.Majority of the diverticulas are of acquired type (10).No diagnosis of the diverticulusis of the vermiform appendix can be made prior to surgery to a great extent.It can be typically detected in patients operated for developing a complication or another reason.In case it is detected in a patient without any complications by means other than surgery ,need for intervention is controversial in the literature .Some are concerned about prophylactic appendectomy (14,15) while others recommend appendectomy (2,16),however when diverticula where detected during the surgery appendectomy is required if it is associated with any complication.We also believe that appendectomy is required in order to prevent development of any events such as choronic abdominal pain, diverticulitis, hemorrhage or perforation , which are common in such diverticulas even in the absence of any complication although we lack any evidance-based outcomes regarding this. ...
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AIM: Presentation of a very rare clinical coincidence MATERIAL-METHOD: A 61-year-old male patient admitted to a surgery clinic sufferıng from right inguinal pain and a mass which sometimes now and then descended down to his scrotum. He had those complaints for 5 years and explained that the mass was located outside extracorporeally but he could push it inside by himself temporarely. In physical examination a reducible right inguinal hernia with gut inside the sac was observed. Surgıcal procedure was advised with the diagnosis of right inguinal hernia. No pathological sign was found in the preoperative tests and he was operated on with spinal anesthesia. FINDINGS: Caecum made partially one wall of the indirect hernia sac and a round shaped appendix vermiformis tough elastical masses on it was observed in the sac. Caecum and the other stuructures that could be seen in the region were macroscopically normal but a femoral hernia sac with omentum inside was found during digital exploration of the femoral canal. Appendectomy was performed because of a possibility of a neoplasia in appendix vermiformis. Then femoral hernia sac was reduced to abdomen by opening of the fascia transversalis. Caecum was prepared and reduced to the abdomen and excess part of the hernia sacs were resected. The operatıon was finished after Mc Way repair had been completed. RESULTS: The patient had no complaint in the postoperatıve period and was discharged on the third postoperative day. The microscopical diagnosis of the specimen was diverticulosis of the appendix vermiformis. The patient had no problems after 30 days following the operation. No similar coincidence had been found in the literature search.
... Mucinous cystadenomas are the most frequent of mucinous appendiceal neoplasms. 3 Appendiceal tumors are safely considered to have low malignant potential; those limited to the appendix itself are generally accepted as being benign. 4 Appendiceal tumors are generally diagnosed as acute appendicitis, or they may be incidental in the course of surgery for unrelated conditions. ...
Article
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INTRODUCTION Appendiceal tumors are rare, late-diagnosed neoplasms that may not be differentiated from adnexal masses even by advanced imaging methods and other diagnostic procedures. They may be asymptomatic and remain undiagnosed until surgery. PRESENTATION OF CASE We report a case of 81-year-old postmenopausal woman presented with abdominal pain. A magnetic resonance imaging revealed right adnexal mass. Laparotomy was performed and detected a 12 cm × 9 cm mucinous tumoral mass arising in the appendix. An appendectomy and a right hemicolectomy with ileo-transverse anastomosis were performed. Histopathological examination was revealed appendiceal mucinous neoplasm with low malignancy potential. DISCUSSION Gastrointestinal tumors such as appendiceal tumors can mimicking adnexal mass. Therefore, appendiceal tumor kept in mind in a patient with diagnosed adnexal mass, especially patient had non-specific clinical symptoms, laboratory and radiologic findings. CONCLUSION Gastrointestinal tumors such as appendiceal tumors kept in mind in a patient with diagnosed adnexal mass.
... Os divertículos podem ocorrer em qualquer parte do tudo digestivo. A presença de divertículos no apêndice cecal é um achado raro 1 originalmente descrito por Kelynack em 1893 2,3 . O diagnóstico pode ser efetuado durante operação, através de exame anátomopatológico de espécimes de necropsia ou de peças cirúrgicas ou, mais raramente, a partir de estudos contrastados do intestino grosso 2 . ...
Article
The authors present three cases report of appendicular diverticulum with associated diverticulitis, one of them asymptomatic. The clinical distinction between acute apendicitis and apendical diverticulitis is very difficult, the later usually with earlier suppuration. The are no consensus regarding preventive surgery for apendical diverticulitis. It is possible that incidence of apendicular diverticulum depends on careful anatomopathological exams.
... Os divertículos podem ocorrer em qualquer parte do tudo digestivo. A presença de divertículos no apêndice cecal é um achado raro 1 originalmente descrito por Kelynack em 1893 2,3 . O diagnóstico pode ser efetuado durante operação, através de exame anátomopatológico de espécimes de necropsia ou de peças cirúrgicas ou, mais raramente, a partir de estudos contrastados do intestino grosso 2 . ...
Article
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The authors present three cases report of appendicular diverticulum with associated diverticulitis, one of them asymptomatic. The clinical distinction between acute apendicitis and apendical diverticulitis is very difficult, the later usually with earlier suppuration. The are no consensus regarding preventive surgery for apendical diverticulitis. It is possible that incidence of apendicular diverticulum depends on careful anatomopathological exams.
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Background: Appendiceal diverticulum (AD) is a rare surgical finding. This entity is classified as either congenital or acquired, with a reported incidence of 0.014% and 0.2-1.7%, respectively. AD can often be associated with acute or chronic appendicitis. Clinically, AD must be identified before any surgical procedure as its concomitant presence with acute or chronic appendicitis increases the risk of perforation and may be associated with underlying neoplasia such as low-grade mucinous adenoma. We hereby report a case of incidental appendiceal diverticulosis associated with acute appendicitis in an attempt to increase the physicians’ perception, knowledge, and awareness of this rare medical condition. Case Presentation: We report a 40-year-old male patient, with no relevant family history, who presented to the Emergency Department after four days of vague and moderate epigastric pain and nausea. The physical examination upon presentation was unremarkable. Computed Tomography (CT) scan was done and was suggestive of an inflamed appendix. The patient underwent an urgent laparoscopic appendectomy. The removed appendix was inflamed and grossly abnormal with multiple diverticulae. The patient had a smooth recovery. Conclusion: Diverticulosis of the appendix is a rare clinical entity and, as in our case, is often diagnosed during or after appendectomy. When associated with acute appendicitis, it may be suspected preoperatively with the appropriate imaging technique. This is of paramount importance as it can rapidly progress to perforation and/or lead to a higher mortality rate.
Article
As compared to acute appendicitis, which is quite common, diverticulum of the appendix is a relatively rare disease. In many cases, diverticulum of the appendix is correctly diagnosed during surgery after an initial diagnosis of appendicitis. We compared 14 patients (7.3%) who exhibited diverticulum of the appendix with 177 patients (92.7%) who did not from a total of 191 patients who underwent surgery following the diagnosis of acute appendicitis over a 2-year period from January 2012 to December 2013. We statistically compared the background, findings upon arrival at hospital, maximum diameter of the appendix, perforation rate, and number of days in hospital of these patients, and found that the perforation rate was significantly higher in patients with diverticulum of the appendix. These results suggested a risk of perforation even in cases of appendicitis with mild inflammation. Advances in diagnostic imaging have made preoperative diagnosis of diverticulum of the appendix via computed tomography possible at least to some extent. If findings suggestive of diverticulum of the appendix are observed, because of the high risk of perforation, surgical treatment should be considered even if the appendicitis is deemed mild.
Article
We report the case of a 64-year-old man who was referred to us with a positive result of the fecal occult blood test. Colonoscopy suggested the presence of a tumor of the appendix, pushing the orifice of the appendix externally. Ultrasonography and computed tomography revealed an enlarged appendix (60 × 20 mm) with polycystic changes. We suspected a mucocele of the appendix and performed laparoscopic appendectomy. However, histopathological examination showed true diverticulosis of the appendix. True diverticulosis of the appendix is rare, and our case is the 26th reported case in Japan. Most reported cases of diverticulosis of the appendix are detected secondary to symptoms or signs of inflammation. However, in this case, the patient did not have any symptoms, and histopathological examination revealed no signs of inflammation; the radiographic findings were consistent with a mucocele of the appendix. Clinicians should consider the following aspects when planning surgery for patients with diverticulosis of the appendix: 1) prevention of perforation in patients showing evidence of inflammation, and 2) differentiation of appendiceal diverticulosis from a tumor.
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Background Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta‐analysis was performed to evaluate the prevalence of DA and its association with neoplasia. Methods A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle–Ottawa scale. Meta‐analysis with risk ratio and random‐effects model was performed using RevMan. Results The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta‐analysis with random‐effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77–50.75, P < 0.00001). Conclusion The strong association with neoplasia in this meta‐analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA.
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Appendiceal diverticulosis is a rare condition that can lead to diverticulitis, which imitates the clinical findings of acute appendicitis. Preoperative diagnosis is difficult, and identification is usually made postoperatively, on the basis of the histological examination of the resected appendix. The case is reported here of a 66-year-old male, who presented with the symptoms and signs of acute appendicitis, which proved on surgery to be due to rupture of an appendiceal diverticulum, with no underlying neoplasm.
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We report a case of successful endoscopic drainage of an ileocecal abscess. A-73-year-old male had an abscess of unknown origin. On admission, Pelvic CT scan revealed a heterogenous mass in the ileocecal lesion and colonoscopy showed that pus was discharged from the vermiform appendix. The patient was on warfarin postoperatively following an artificial valve replacement for aortic regurgitation, and thus had the tendency to bleed extensively, ruling out an emergency operation. For the confirmation of an invaginated abscess, a contrasting ERCP tube was inserted into the appendix and the mass was fully contrasted. After insertion of a guide wire, an ERBD tube was inserted and a large quantity of white matter flowed out and was drained off. After the patient had achieved a generally stable condition, appendectomy was performed. From the pathological findings, perforation of the vermiform appendix diverticulum was believed to be the major cause of the abscess.
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Anatomical relationships and gross appearanceBlood supplyLymphatic drainageNerve supplyPhysiologyHistology
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Diverticulum of the appendix has been often reported in Europe and the United States. However, in Japan, only 44 cases have appeared in the literature and only 4 of them were diagnosed as diverticulum of the appendix before surgery. Five patients diagnosed a having diverticulum of the appendix are presented in this report: Case 1. A patient diagnosed as having appendicitis underwent surgery. A diverticulum was found in resected specimen of the appendix. Case 2. After a diagnosis of appendicular diverticulum was made by barium enema examination, appendectomy was performed. The others (cases 3-5) were diagnosed by barium enema examination. The number of cases without symptoms is considered to increase with careful investigation, and we suggest that surgery may not be required in such cases.
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Objective: Diverticulosis of vermiform appendix (DVA) is a rare condition. It is usually diagnosed on barium enema, after appendectomy or by studying autopsy specimens. We report the first case of DVA diagnosed by colonoscopy. We also evaluated 1735 cases of DVA and performed qualitative meta-analysis (QMA) on the subject of DVA. Methods: 63 year old man with hematochezia was evaluated with colonoscopy. There was left colon diverticulosis, internal hemorrhoids and a benign colon polyp; the scope was passed onto the appendicular ostium. In the lumen of the appendix openings of two diverticula were seen. PubMed Search for DVA without time or language barrier was carried out. To facilitate QMA, summary sheets of publications were created. QMA was performed using the well-established methods of Qualitative Research e.g. Diagramming, Theme Repetition, Theme Saturation and Investigator Reflexivity. Results: The search produced 1735 cases of DVA for QMA. Among those patients where gender information was available, 61.6% were men. Single diverticulum was reported in 46.2%; multiple diverticula were seen in 53.8%; the mean age was 48.6 years. Incidence of DVA was 0.4% to 2.0%. Majority are acquired type (pseudo-diverticula) which explains the higher perforation rate. The question of prophylactic appendectomy in DVA is controversial. Conclusion: We report the first case of DVA diagnosed by colonoscopy. The prevalence of DVA is 0.4% to 2.0%. There is a slight male predominance. Majority are acquired type. Compared to usual appendicitis, diverticulitis in DVA occurs at a later age and incidence of perforation is higher. © 2011 Japan International Cultural Exchange Foundation & Japan Health Sciences University.
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A 82-year-old woman seen for lower abdominal pain was found in computed tomography to have a grape-like cystic mass with increased fat density below the ileocecal region. We conducted appendectomy under a diagnosis of acute appendicitis or appendiceal tumor. Resected specimen showed diverticulosis. Pathological examination indicated acute inflammation only at the tip of the appendix, and chronic inflammation at the true diverticulosis. True diverticulosis is rare, with only 6 cases reported in the Japanese literature. Some investigators recommend prophylactic appendectomy for asymptomatic appendiceal diverticulosis because it is highly prone to perforate in the presence of acute inflammation. This opinion has been based on inaccurate citation from outdated literature, acute appendicitis has equivalent risk of perforation among aged patients 65 years and older. We hold that no reason exists for prophylactic appendectomy in asymptomatic appendiceal diverticulosis.
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Diverticulitis has long been known to affect the right colon, and in recent years, our understanding has evolved in regard to the underlying cause. Appendiceal diverticulitis has yet to gain widespread recognition despite the fact that it was first described in 1893. Commonly dismissed by surgeons and pathologists as a variant of true appendicitis, appendiceal diverticulitis is a discrete clinical process that must be considered in the appropriate setting. We describe a case of appendiceal diverticulitis in a previously healthy 59-year-old man and review the literature.
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A variety of conditions of the appendix come to the pathologist's attention from time to time, other than appendicitis and tumours. This chapter deals first with developmental abnormalities, including agenesis and duplication. The appendix may be affected by diverticulitis, torsion and intussusception, conditions that may be considered as ‘appendicitis’ at patient presentation, but are pathologically distinct and have different natural histories and clinical implications. A number of conditions peculiar to females, most commonly endometriosis, are presented. Other conditions dealt with are cystic fibrosis, foreign bodies and appendiceal melanosis.
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Torsion of the Diverticulum of the Appendix We report a case of a 1-year-old girl, operated on due to the symptoms of acute appendicitis. Torsion, necrosis and perforation of the large diverticulum of the appendix vermiformis , causing peritonitis were found during the operation. The complete luminary connection between appendix and the diverticulum was proved. Although appendix vermiformis itself was not the reason for the peritonitis, it was removed together with the diverticulum. The child's recovery after the operation was stable. The morphology revealed that the diverticulum of appendix vermiformis generally possessed features typical of a large intestine columnar epithelium, while its other layers, including a muscular layer and an irregularly expanded sub-mucosal layer, remained similar to the wall of the appendix. We suggest that the torsion of the true congenital diverticulum of the vermiform appendix mimicked acute appendicitis and caused peritonitis in the above-mentioned girl.
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Pseudodivertikel der Appendix sind selten. Histologisch handelt es sich um Mukosahernien durch Lücken in der Muskulatur. Häufig findet sich im Bereich eines derartigen Schleimhautvorfalles ein Gefäßdurchtritt. Die Pseudodivertikel neigen zu entzündlichen Komplikationen.
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Article
症例は79歳,男性.腹痛を主訴に当科紹介・受診となった.腹部造影CTで虫垂が多房性嚢胞状に腫大していたため虫垂粘液嚢胞と診断し回盲部切除術を施行した.術後病理組織学的診断で虫垂憩室炎と診断された.虫垂憩室炎は,虫垂切除症例中約0.004~2.2%と比較的な稀な疾患であり,特異的な所見に乏しいため術前確定診断にいたるのは難しい.また画像上多房性嚢胞状に腫大する形態を呈する虫垂憩室炎は稀であり,術前診断が困難であったが,画像診断の進歩とともに今後このような症例は増加すると考えられる.虫垂嚢胞性腫瘍との鑑別診断をするうえで考慮すべき疾患であると考えられるので若干の文献的考察を加え報告する.
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Vermiform appendix is an unusual site of diverticulosis. We present 3 examples of this entity and briefly review its pathogenesis and clinical significance. As a general rule, appendiceal diverticula are multiple, acquired naturally, and rarely associated with complications.
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To assess the prevalence of acquired diverticulum of the appendix (DA), including incipient forms and its possible significance as a marker of local/regional neoplasms. The pathology database at Hvidovre Hospital was searched for appendix specimens, received between 2001 and 2010, coded for DA or for a space-occupying lesion. Slides were reviewed to determine DA status and the nature of lesions possibly causing DA. Among 4413 appendix specimens, DA were identified in 39 (0.9%, CI 0.6% to 1.2%) cases, 17 (43.6%, 28.0% to 59.2%) of which additionally harboured an appendiceal neoplasm/neoplastic precursor, whereas this figure was 1.2% (CI 0.9% to 1.6%) for non-DA specimens (p<0.0001). Six of the 39 DA specimens comprised incipient DA, three of which coexisted with appendiceal neoplasms. In addition, local/regional non-neoplastic lesions (six cases) and colorectal carcinomas (four cases) coexisted with DA. DA has significance as a putative marker of local/regional neoplasms. Therefore, a DA specimen proved significantly more likely to harbour a neoplastic growth than a non-DA counterpart. Submission for microscopy of the entire DA specimen, whether transmural or only incipient, and a comment in the pathology report on the occasional concurrence of local/regional neoplasms in this setting seem appropriate. The observation of DA may thus provide a valuable contribution in the diagnostic process.
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Acute appendicitis is the commonest nonobstetric cause of acute abdomen in pregnancy. Appendiceal diverticulitis, albeit very rare, warrants special attention owing to it's often insidious presentation and increased risk of perforation coupled with difficulty in diagnosing appendicitis in pregnancy. We describe a case of appendiceal diverticulitis in pregnancy diagnosed with ultrasound and MRI and review the imaging manifestations of this entity. To the best of our knowledge, this is the second case of appendiceal diverticulitis in pregnancy reported so far and the first report describing the MRI findings in appendiceal diverticulitis.
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Appendiceal diverticulitis has been difficult to distinguish from acute appendicitis clinically and radiologically. The purpose of this study was to describe multidetector computed tomography (MDCT) features of cases of pathologically proved appendiceal diverticulitis at our institution over a 36-month period. Seven of 156 patients who underwent appendectomy with the preoperative diagnosis of acute appendicitis were pathologically diagnosed with appendiceal diverticulitis. Two radiologists reviewed the MDCT images for these 7 patients. On MDCT, a total of 8 inflamed diverticula were visualized as small fluid-filled luminal structures with thick enhanced walls or as solid enhanced masses protruding from the appendix for 6 of 7 patients. For 2 of these 6 patients, MDCT revealed a total of 5 normal diverticula visualized as small air-filled luminal structures with thin walls. For 1 of the 7 patients, neither inflamed or normal diverticula could be identified on MDCT. MDCT revealed appendiceal wall thickening with a tiny or no luminal fluid collection for 5 patients and with a moderate fluid collection for 1 patient, and a normal appendiceal wall for 1 patient. Our results suggest that MDCT can reveal appendiceal diverticula and has potential in the preoperative diagnosis of appendiceal diverticulitis.
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Arthritis both bacterial and nonbacterial, has been reported as a rare complication of varicella infection in children. The arthritis is manifested as a swollen, inflamed joint appearing within a week after the onset of a varicella rash. Bacterial arthritis is thought to result from hematogenous spread of organisms that have colonized varicella skin lesions. It requires antibiotic therapy and occasional drainage of the joint. The nonbacterial arthritis resolves without treatment. Although this form of arthritis is presumed to be viral, isolation of varicella zoster virus from joint fluid has not been documented previously. A case of an 8 yr old girl is reported.
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Bowel perforation is an infrequent complication of neonatal Hirschsprung disease, attributed to distal functional obstruction and proximal luminal distention causing ischemic necrosis of the bowel wall. Neonatal appendiceal perforation with Hirschsprung disease has been reported with abscess formation and, also, without significant gross inflammation. Pseudodiverticula of the appendix have occurred in adults with or without inflammation and with or without associated appendicitis or perforation with periappendicitis. Increased intraluminal distension and muscular contraction have been implicated in the pathogenesis. We are not aware of previous reports on pseudodiverticulum of the appendix in infants. A patient with total ganglionosis of the colon with appendiceal pseudodiverticulitis and periappendicitis is presented.
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The incidence, clinical features and pathology of nine cases of diverticula of the appendix in Malaysians are reported. The findings are discussed and compared with those previously reported. The pathogenesis of the lesion in eight cases is unknown. The rare association of lumenal obstruction by a carcinoid tumour and diverticulum formation in the appendix is seen in one case.
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Diverticulosis of the appendix is rarely reported. Two cases with this condition, including a unique example of appendiceal diverticulosis presenting at herniorrhaphy, are described. The aetiology of the condition and factors involved in incidental appendicectomy are considered.
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We have discussed a case of appendiceal diverticulitis diagnosed at laparotomy, and reviewed the histologic and clinical findings. Although infrequently encountered, appendiceal diverticulitis must be entertained in the differential diagnosis of pain in the right lower quadrant, especially in the adult patient.
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A case of appendicitis that was associated with a rare congenital diverticulum of the appendix is presented, along with the results of a retrospective study of diverticulosis of the appendix over a 10-year period. The incidence of the condition in this series (0.65%) is similar to other published series; however, two cases involved rare congenital diverticula--only 43 of such cases have been previously recorded in the medical literature world-wide. The average age of patients who present with acute appendicitis with acquired diverticula (37.8 years) is greater than that of patients without the condition. The perforation rate of an inflamed appendix when diverticula were present (27%) was higher than when no diverticula existed (6.6%). Because of the earlier and higher perforation rate, it is proposed that appendicectomy be performed if an appendix with diverticula is found during the course of a laparotomy for some other condition.
Article
This paper presents a study of diverticulosis of the vermiform appendix in patients with cystic fibrosis. The records of two hospitals were reviewed. A total of 39 autopsy specimens and 18 surgical specimens were obtained. Diverticulosis of the appendix was found in 14 per cent (eight of 57) of all appendices. Two of these cases also showed diverticulitis. These results stand in contrast to the incidence of diverticulosis of the appendix in the general population, which has been measured at 1 to 2 per cent in various reviews.
Article
The vermiform appendix can be the site of development of diverticula which may suffer either inflammatory complications with or without appendicitis or may only be an incidental finding in an uninflamed appendix. This is a retrospective study of 10 of 575 cases of consecutive appendices removed and examined within a year, with single or multiple appendiceal diverticula with diverticulitis and peridiverticulitis. In six of the 10, the lumen of the appendix did not show any inflammatory changes. In conclusion, one could assume that inflammatory complications of the appendiceal diverticula, although they may mimic acute appendicitis, are quite distinct clinical entities. Acute appendicitis in the presence of appendiceal diverticula may carry an earlier and higher rate of perforation and appendiceal diverticula, as an incidental finding, may justify appendectomy on occasion.
Article
The significant rôle of the vermiform appendix in the causation of perityphilitic suppuration was established by Fitz,¹ of Boston, in 1886. This was almost fifty years ago, and in the intervening years, thanks to the fruitful labors of Pasteur and Lister, surgery has broadened in its scope from a science concerned primarily with the dressing of wounds to one holding an important position in the treatment of disease. Knowledge concerning the recognition of the clinical picture of appendicitis and the surgical technicalities involved in its removal have grown apace, but information concerning the nature of the origin of appendicitis remains almost as obscure as when Fitz made his prophetic pronouncement. Appendicitis continues to prove fatal, and if one considers actuarial tabulations, the mortality is increasing. In the last twenty-five years² there has been an increase of 30 per cent. Whether this is apparent or real is not yet
Article
The subject of diverticulum formation in the appendix has apparently aroused the interest of but few writers in Europe and America. It seems rather astonishing in these days of experimental investigation of almost every conceivable subject that this interesting, if relatively unimportant, process has never, so far as I can ascertain, been produced or studied experimentally. Hypotheses have been based on morphologic observations of the appendix itself, together with the application to the appendix of a few experiments made in the large and small intestine. The results are unsatisfactory because some of them, reported by earlier observers, either could not be reproduced, or produced entirely different and contradictory results, when repeated by others.It seems, therefore, that this condition deserves further investigation, particularly so inasmuch as I have become convinced during the past year that the condition is not nearly so infrequent as the few reported cases would lead one
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Eighteen new cases of acquired appendiceal diverticula are reported. The majority, eleven patients, showed evidence of acute or healed appendicitis, supporting the widely accepted theory that inflammation is an essential factor in the development. There were, however, seven cases where no trace of recent or past inflammatory reaction was found, which suggests that other as yet undetected mechanisms may be operative.
Article
DIVERTICULOSIS of the vermiform appendix, as of the colon proper, is characterized by the formation of pouches or pockets leading off from the lumen. They may be congenital or acquired. The congenital variety is rare and is characterized by the presence of all the layers of the appendiceal wall. The walls of acquired diverticula are formed by mucosa and submucosa, but the muscularis is absent or very attentuated. These diverticula are produced after an abnormal increase in muscular activity with increase in intra-appendicular pressure. Acquired diverticulum of the appendix was first described by Kelynak1 in 1893. In 1926, Spriggs and Marxer2 recorded the first case in which the diagnosis was made radiologically. Most of the cases reported or described in the literature have been found accidentally, at operation or during routine autopsy examination. In 1946, Gilmore and Mahan3 reported another case in which the diagnosis was made
Article
Diverticulosis of the bowel with or without its complications is a fairly common surgical situation. Morbidity statistics range from 5% to 10% of the population, 20% of the patients having symptoms which may be ascribed to the presence of the lesion. The usual form of diverticulum respresents a protrusion of the lumen of the bowel through its retaining wall whereby the sacculation projects beyond the serosal surface. It is essentially an outpouching of the mucosa through a weakened part of any wall. Our presentation is concerned with the variant which is called the intramural and dissecting type. In this form the lumen herniates into the wall of the intestine, and then the sacculation burrows its way along the wall. Dissecting (intramural) diverticulitis is a rodent form of diverticulum.2 It begins as an extrusion of the lumen. The mucosa which originally covered the sacculation disintegrates, but remnants identify the origin
Article
The finding of diverticula in the gastrointestinal tract is an exceedingly frequent occurrence in the course of routine x-ray examination. They have been encountered all the way from the upper esophagus to the lower sigmoid. They vary from symptom-producing saccular protrusions to asymptomatic incidental discoveries. It is the purpose of this brief presentation merely to record a most unusual set of diverticula arising in the vermiform appendix. In this instance the discovery was incidental and bore no relation to the patient's symptoms or to the clinical picture. Serial small bowel films were obtained, and the terminal ileum was well demonstrated, ruling out the possibility that it was the site of the diverticula. The rarity of diverticula arising in the appendix suggests the need for recording this case in the literature. Maissa found a single case in 10,000 serial examinations of the intestinal tract.
Article
IN SPITE of the large number of papers written on the subject, diverticulosis and diverticulitis of the appendix are still believed to be rare. While the conditions are not common, one cannot judge their incidence from published reports. The frequency with which they are found will be in direct proportion to the effort expended in searching for them. This was pointed out by Stout,1 who found five cases in one year with special study, whereas only one case had been reported from the same institution in the previous 10 years. The reported incidence is variable, but the lowest was found by the Army Institute of Pathology, 42 cases among 51,525 appendixes studied, or 0.08 per cent.2 The highest was reported by Mertens,3 2.8 per cent. This paper is being presented in order to draw attention to this condition and to report 16 cases. ETIOLOGY AND PATHOLOGICAL PHYSIOLOGY
Article
Summary Spasm of the descending colon co-existing with spasm of both, the proximal and the distal ends of the appendix was observed in a highly neurotic young adult. Spasm along both ends of the appendix resulted in a diverticulum-like sacculation of the non-spastic, relaxed middle portion of the vermiform appendix, a morphological appearance hitherto often not described. The characteristic X-ray picture as observed during the painful period, with a complete restoration to normal, in a free interval, prove conclusively, that the changes described were purely of functional origin.
Article
Analysis of ninety cases of diverticulum of the appendix makes it possible for us to classify this lesion into five main groups, thus recognizing this disease as a definite pathologic entity.
Article
Vermiform appendix is an unusual site of diverticulosis. We present 3 examples of this entity and briefly review its pathogenesis and clinical significance. As a general rule, appendiceal diverticula are multiple, acquired naturally, and rarely associated with complications.